DESCRIPTION
Facet joint injections and/or medial branch blocks involve medication injected directly into the joints or the nerve around the joints in the spine to diagnose and treat neck and back pain. A potential source of spinal pain is the posterior zygapophysial joint (facet, Z joint), which adjoins adjacent vertebrae and is innervated by medial branches of the dorsal spinal nerves at two levels.
There is no single history or physical examination finding that can diagnose facet joint syndrome. Diagnosis can be made when controlled local anesthetic blocks of the medial branches of the posterior rami of the spinal nerves that supply the painful joint(s) provides relief of the target pain. In dual controlled diagnostic testing, the individual typically receives injections of anesthetics with different, predictable durations of action (comparative anesthetic blocks). Alternatively, the diagnostic testing can be done using true placebos (inactive substances) as well as the active agent in a double-blind manner. The underlying premise for these injections is that the facet joints have been shown to be the source of neck and back pain using reliable methods. Treatment options for individuals with confirmed facet joint pain include therapeutic facet joint injection using longer acting anesthetic or steroid.
POLICY
Facet joint injections are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Ultrasound guidance for facet joint needle placement is considered investigational.
MEDICAL APPROPRIATENESS
Facet joint injections are considered medically appropriate if ALL of the following are met:
Injections are performed under fluoroscopic imaging guidance
Absence of ALL of the following:
Allergy to the medication to be administered
Localized infection in the region to be injected
Systemic infection
Other comorbidities that could be exacerbated by steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.)
Radicular symptoms due to nerve root compression shown on imaging (e.g., stenosis, disc herniation, etc.)
Planned procedure at fused spinal level
Planned procedure at the site of a previously successful radiofrequency ablation
Request is for ANY ONE of the following:
Diagnostic dual controlled medial branch blocks when ANY ONE of the following are met:
Initial injection when ALL of the following are met:
Presence of moderate to severe primarily axial back or neck pain for at least 3 months duration that is worsened by extension, lateral bending, or rotation, that interferes with performance of daily activities
No more than two unilateral or bilateral levels are planned per session (up to 4 injections), regardless of region (cervical/thoracic and lumbar)
Failure of minimum four weeks conservative treatment including ALL of the following:
Analgesic or anti-inflammatory medications
Activity modification
Chiropractic or physical therapy, or detailed professionally-directed home exercise program
Appropriate imaging has been performed and other reasonable sources of pain have been ruled out (such as infection, tumor, or fracture)
Second injection when ALL of the following are met:
Performed at least two weeks after initial injection
Documentation of at least 80% reduction in pain and improvement in function for the expected duration of the analgesic
No more than 4 total sessions are done within a rolling 12 months per spinal region (cervical/thoracic or lumbar)
No more than two unilateral or bilateral levels are planned per session (up to 4 injections), regardless of region (cervical/thoracic and lumbar)
Therapeutic facet injection indicated for ANY ONE of the following:
For initial treatment of a facet cyst causing nerve root compression or displacement, confirmed by appropriate imaging (such as MRI or CT), with other symptom causes ruled out
One-time repeat facet cyst rupture if the symptoms return and the medical record showed at least 50% reduction in pain and improvement in function after initial procedure
Recurrent nonradicular neck or back pain when ALL of the following are met:
Indicated for ANY ONE of the following:
For initial injection, at least 75% pain relief from baseline scores achieved from diagnostic facet joint or medial branch nerve blocks
For repeat therapeutic injection, greater than 50% improvement in pain and function for at least ten (10) weeks achieved from previous therapeutic injection
No more than two non-fused spine levels for each spinal region (cervical/thoracic or lumbar) may be treated in one session [unilateral or bilateral]
Prior history of not more than four (4) therapeutic facet joint sessions within a calendar year for each spinal region (cervical/thoracic or lumbar)
No other injection for pain treatment (e.g., epidural steroid injection, sacroiliac joint injection, lumbar sympathetic block, trigger point injections) given within three (3) days of facet joint injection
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine. (2010). Practice guidelines for chronic pain management. Retrieved February 21, 2017 from http://www.asahq.org/quality-and-practice-management/standards-and-guidelines.
Bani, A., Spetzger, U., & Gilsbach, J. M. (2002). Indications for and benefits of lumbar facet joint block: analysis of 230 consecutive patients. Neurosurgical Focus, 13 (2), E11. (Level 4 evidence)
Cohen, S. P., & Raja, S. N. (2007). Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology, 106 (3), 591–614. (Level 2 evidence)
Falco, F. J., Manchikanti, L., Datta, S., Wargo, B. W., Geffert, S., Bryce, D. A., et al. (2012). Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician, 15(6), E839–E868. (Level 2 evidence)
Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician, 16, S49-S283. (Level 2 evidence)
Manchikanti, L., Boswell, M., Singh, V., Benyamin, R., Fellows, B., Abdi, S., et al. (2009). Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician, 12, 699-802. (Level 2 evidence)
Manchikanti, L., Singh, V., Kloth, D., Slipman, C. W., Jasper, J. F., Trescot, A. M., et al. (2001). Interventional techniques in the management of chronic pain: Part 2.0. Pain Physician, 4 (1), 24–96. (Level 1 evidence)
OrthoNet LLC. (2018, February). Facet joint block injection. Received from OrthoNet on April 24, 2018.
Peh W. (2011). Image-guided facet joint injection. Biomedical Imaging and Intervention Journal, 7 (1), e4. (Level 5 evidence)
Turning Point Healthcare Solutions. (2022). Facet joint injections. Retrieved January 19, 2023 from Turning Point Healthcare Solutions.
ORIGINAL EFFECTIVE DATE: 4/1999
MOST RECENT REVIEW DATE: 7/11/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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